AccessPay Change to salary packaging arrangements form

Transcription

1 AccessPay Change to salary packaging arrangements form Send completed form to or post to PO Box 1238 Adelaide SA 5001 Transcriber s Note: Information to be filled in is indicated by underscores. Check boxes are indicated by square brackets enclosing an underscore [_]. Step 1: Help us identify you First name: Surname: Date of birth: / / Subscriber number: Employer name: Mobile Number: address: Step 2. Tell us when you want these changes to take place Changes need to be submitted a minimum of 8 business days prior to your pay day (this could vary for weekly or monthly pay cycles). If start date is not specified, changes will take effect on your next pay date. When the changes to start?* / / Would you like this payment/s to be: [_] Ongoing [_] Once off [_] Short term If short term, how many pay cycles should the change go for?

2 Step 3. Outline your salary packaging payments Fill in all payments you would like made from the above date. You will need to include all current payments and any changes. The total at the bottom will be your new total deduction. s not listed will be removed. BSB (max 6 Which account would you like us to deposit Account number (max 9 reference (if relevant) Mortgage repayment (excluding investment properties) Personal loan repayment Rent Credit card Education payments (school fees, child care, HELP) Salary Packaging and Employee (General Living Expenses) Please complete Salary Packaging and Employee application on Salary Packaging and Employee (Entertainment Benefits) page 2 Please complete Salary Packaging and Employee application on page 2 Health insurance Household bills (rates, power, groceries etc) per pay cycle

3 Entertainment Benefits Other. Please specify. BSB (max 6 Which account would you like us to deposit Account number (max 9 reference (if relevant) per pay cycle New Total salary packaging amount (for payments only, this excludes your ongoing fee) See page 2 for the documentation you need to submit to support your payments. If supporting documentation is not provided, requesting changes will not be actioned. Signature: Date: / /

4 Salary Packaging and Employee application Primary Cardholder Please tick the box of the identifying document and supply the corresponding document number: [_] Australian Driver s Licence [_] Australian Proof of Age Card [_] Australian Passport [_] Other Passport please specify country of issue: [_] Document number: (Example: licence number, card number, passport number) Partner card application: Please provide the following details for the Partner Card holder (if you would like one). Partner cardholders must be 16 years or older. All given names Surname Date of Birth / / address Salary Packaging and Employee Acknowledgments and Consents: 1. I request to receive an AccessPay Salary Packaging and Employee and agree to receiving disclosures about this card online. I understand that the Product Disclosure Statement and Financial Services Guide is available online ( and further information on how to activate my card will be sent to me with my card. 2. I understand the AccessPay Salary Packaging and Employee is issued by Heritage Bank Limited ABN , AFSL ACL I understand Heritage Bank Limited is not responsible for my salary deduction arrangements. 3. I confirm where information has been provided on behalf of a partner cardholder, the partner cardholder has provided me authority to request an AccessPay Salary Packaging and Employee on their behalf. I understand I will be liable

5 to Heritage, my employer and my salary packaging provider for any loss arising from the use of the card by the partner cardholder. I request that the changes shown on this form be made to my salary packaging arrangements and confirm my continuing compliance with my employer s policies and procedures. I also confirm that any reimbursement request is in relation to expenses already paid by me. Signature: Date: / / Supporting documentation required: type: Mortgage repayment (excluding investment properties) Personal loan repayment Rent Credit card Education payments (school fees, child care, HELP) Salary Packaging and Employee Benefits Card (General Living Expenses) Salary Packaging and Employee Benefits Card (Entertainment Benefits) Form above. Health insurance Household bills (rates, power, groceries etc.) Entertainment Benefits Includes dine-in meals, holiday accommodation and car hire, and taxis. Please provide: Current statement showing the BSB, account number, amount owing and 2 Current statement showing the BSB, account number, amount owing and 2 Current lease or rental declaration showing your name, address, rent amount, length of lease and proof of 2 Credit card statement showing amount owing and up to 12 months worth of statements. Invoice showing amount owing and proof of up to 12 months worth of payments. Form above. Form above. Policy document showing the amount owing and proof of 2 consecutive payments. Invoice showing payment details, amount owing and proof of payment Invoice showing amount owing and proof of payment. Manage your changes online or download our app! Visit accesspay.com.au for more information.